Knee Surgery? Think Twice

Knee Surgery? Think Twice

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During the 4000 year history of medicine, doctors have done terrible things to patients. We gave them arsenic and mercury; we bled them; we made them vomit, gave them laxatives; we made them hot and we made them cold.

A lot of this was nonsense, sometimes dangerous—and even deadly. You would expect that eventually patients would catch on and learn to avoid doctors, but most didn’t. Many got better despite the dreadful treatments and felt only gratitude.

The magic of medical success has always been, and to a large extent still is, the remarkable power of the placebo effect—getting better as a result of a tincture of time and the magical power of hopeful expectations. Many popular treatments are popular more because of placebo effect than because of any physiologic changes.

Placebo is the best medicine ever invented.

The placebo effect is endlessly fascinating: we know that 2 pills produce a greater placebo effect than 1, that brand-named pills work better than a non-branded; that expensive pills are more powerful; and that placebos work even when patients know they are placebos. And placebo injections work even better than placebo pills.

The study of placebo effect in surgery has lagged far behind its role in medicine because doing placebo surgery is harder than giving a placebo pill. And there is every reason to believe that surgery is especially prone to placebo effects. The more dramatic the procedure, the more likely it raises hope of cure.

“Quick, operate before the patient gets better” is one of those jokes orthopedic surgeons tell among themselves, barely covering a hard truth: that a lot of elective surgery might be unnecessary or even harmful.

Dr Teppo Jarvinen is the orthopedic surgeon best qualified to explain this issue. As the Jane and Aatos Erkko Foundation Clinical Professor of Orthopedics and Traumatology in the University of Helsinki, he was principal investigator in the most rigorous study of placebo-controlled knee surgery. Dr Jarvinen writes: “Accumulating evidence now proves that much of arthroscopic (keyhole) knee surgery may be unnecessary because the results are no better than placebo.

“This is an especially startling finding because this is the second most common surgical procedure in the world (after cataract surgery). Every year, about 1 million people undergo this procedure in the US alone. And for most, there is likely no benefit compared with doing nothing. The surgery is done so often because it has a perfect biological rationale and intuitively makes perfect sense. There is a lesion (‘damaged meniscus’) that can actually be easily identified through the keyhole surgery. The therapeutic procedure—trimming the ragged edges off a torn meniscus and smoothing the edges of what remains—takes no more than 15 minutes.

“So, picture yourself as an orthopedic surgeon. How great to feel that you are doing something exceptionally useful for your patients. And the knee surgery patients generally do get better and feel grateful—90% report being satisfied after the surgery. They believe that the surgery has fixed their knee problem.

“And to cap it all, insurance companies pay well for the procedure.

“There is only one fly in the ointment in this ‘almost-too-good-to-be-true’ story—it is too good to be true. There is little proof that this kind of keyhole surgery for knee pain actually works.

“The only previous placebo-controlled study in patients with advanced knee osteoarthritis found that actual surgery was no better than sham surgery (skin incisions only). Published 10 years ago, this report marked an important turning point for the orthopedic community, provoking unprecedented criticism and even hostility. Not surprising since it was such a blow to professional pride and a potential threat to a very common and lucrative orthopedic procedure.

“My team decided to repeat the study, but with patients who had only a torn meniscus. Patients with a torn meniscus seemed more likely to respond to surgery because they didn’t have all the nonspecific damage associated with advanced osteoarthritis.

“We inserted an arthroscope through small ‘keyholes’ in the skin, which allowed us to see inside the knee. Through this hole we inserted tools that could trim the torn meniscus and smooth ragged edges of what remained.

“The 146 volunteer patients all received anesthesia and incisions. Half received actual surgery; the other half got the sham procedure, which was just taking a peek inside the knee, but no trimming. The patients didn’t know which procedure they got—real surgery or sham surgery.

“Both groups had equivalent results. A year later, approximately 80% of patients in both groups said their knees felt better, and over 90% said they would choose the same method again, even the patients who had fake surgery.

“After the publication of our study, we have been asked many times whether our findings were completely surprising or unexpected?

“Actually there is no reason to be surprised. A few years ago, a Harvard group published a pivotal study which showed that meniscal tears are very common in all middle-aged people, irrespective of whether or not they have knee pain. In essence, meniscal tears (or ‘wear’ as we call it now) seem to be a very normal finding in an MRI scan.

“In 1998, a US surgeon had his orthopedic brother carry out keyhole surgery to his own knee under local anesthesia. He asked his brother to ‘poke around’ within the knee and showed that meniscus is completely insensitive to pain. Although commonly ignored by most orthopedic peers, his experience makes one wonder how such a dull tissue could be the origin to knee pain.

“Now you’re probably wondering, who exactly needs knee surgery? Frankly, that’s still a complicated question, but let me simplify it by saying that without a true traumatic event (for example, really twisting your knee) resulting in your knee filling up with blood (truly swollen knee). If you are able to move your knee freely (even with some possible pain), there is no urgent need to have your knee ‘scoped.’ Rather, go and see your physiotherapist, start a good rehab program and give it some 3-4 months to let nature take its course. If you still have persistent pain, you may then consider consulting an orthopedic surgeon.

“I heard a beautiful analogy that hopefully helps middle-aged people like me adjust to painful knees—degenerative meniscus tears are like the wrinkles that come with aging and should be treated accordingly.”

Great advice from Dr Jarvinen. His is one of those landmark studies that should change the world. Patients beware before accepting the knife. Insurance companies take note in establishing standards for reimbursement. Guideline makers insert watchful waiting and rehab before recommending surgery. And surgeons, adjust your practice.

Everyone talks about evidence-based medicine, but often there is a long time lag before compelling evidence actually has an impact on clinical practice. This is bad for the patient, bad for the health care system, and bad for society.

We shouldn’t continue doing senseless, expensive, and potentially harmful procedures just because they produce a strong placebo effect.

My knees are aching a bit as I write this and certainly make themselves known every time I climb up a flight of stairs. None of my body parts works as well as they once did. And my mind seems increasingly to be out to lunch.

Aging will do that to you. There is not a medical or surgical solution to the wear and tear of life. If you have bum knees, think exercise and weight loss before submitting to the knife.

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